1 Preventing FASD through providing addictions treatment and related support for First nations and inuit women in canada RESEARCH TO INFORM PRACTICE AND POLICY This information sheet summarizes the findings of an exploratory study undertaken in 2008 by researchers at the British Columbia Centre of Excellence for Women s Health, with the participation of treatment providers and health system planners responsible for programming serving First Nations and Inuit women from across Canada. The study was funded by the First Nations and Inuit Health Branch (FNIHB), Health Canada. The goal of the study was to inform the federal government as to opportunities for improving substance use treatment and support for First Nations and Inuit women who are at risk of having a child with Fetal Alcohol Spectrum Disorder (FASD).
2 Methods Literature review - A review was undertaken of Canadian and international literature on substance use interventions shown to be effective in helping pregnant women reduce their use of alcohol, tobacco and other substances and promote their overall health. The review focussed where possible on information pertaining directly to Aboriginal (First Nation, Inuit and Metis) women in Canada, particularly those at risk who live on First Nations reserves or in Inuit communities. The review determined that there is little literature that focuses specifically on substance use treatment for First Nations and Inuit women, or First Nations and Inuit women and FASD prevention. Virtual focus groups - Given the lack of formal literature on the topic, the perspectives of researchers, service providers and health system planners working on Aboriginal women s health from across Canada were 1 sought through a series of virtual focus groups. Seven virtual focus groups were held in January and February 2008 using a web meeting format. Service providers and/or government employees working for the National Native Alcohol and Drug Abuse Program (NNADAP), FNIHB s maternal and child health programs, and the Community Action Program for Children (CAPC), as well as researchers and professionals working with First Nations and Inuit organizations with expertise in women s health and substance use were invited to participate by . Fifty-six people indicated interest in participating, 30 attended the focus groups 1, and six were followed up by phone when they were unable to attend. The key informants residing in urban and rural communities, were both men and women, and came from six provinces and three territories. The focus groups were guided by the five questions listed at the end of this report. Note that it was planned to include First Nations and Inuit women /mothers who have faced alcohol problems and related health and social problems, however there was not adequate time for the engagement process deemed ethical for their inclusion. Foundations The following three considerations guided the research approach, and were reinforced by the study participants: Integrating gender and cultural sensitivity and recognizing difference - When attending to gender and culture, and their interaction, it is important to recognise that there is no generic First Nations woman or Inuit woman, and therefore no one-size-fits-all answer to what treatment and other systemic responses are needed. Taking a holistic, community-based approach When planning for substance use and related health and social services, a holistic and Aboriginal approach to prevention and treatment is important, with a notable emphasis on the need for a holistic approach to care (mental, physical, emotional and spiritual) that encompasses the community context while reflecting the uniqueness of each woman s experience. 02 Providing women-centred health care The health of Aboriginal women does not exist in isolation from the well-being of their families (however they define family) and the broader community, yet women s health needs can be obscured when only a family or community-centred model is applied. It is important to bring a focus to women s health, while honouring that it is nested within many other community and structural constraints and supports. Women-centred care addresses issues beyond traditional medical interventions; it places health in its broad social context and aims to be participatory, empowering, holistic, trauma-informed, individualized, comprehensive and respectful of diversity.
3 CONTINUUM of CARE MODEL Four key service components were identified in a continuum of care for women with substance use concerns, grounded in two foundational communitywide practices (awareness building/ stigma reduction and community-wide support and change): 1 Discussion and brief intervention which involves constructive and compassionate discussion with all women of childbearing years and their support networks. This involves confronting professional discomfort with talking about substance use, and the stigma attached to being a woman and mother with substance use problems, through education of the broader community and building awareness of FASD as a preventable disability through focused and broadly distributed messaging. Often it is not clear who are all the possible providers of this level of support in Aboriginal communities. 2 Outreach and engagement includes adjusting and tailoring our approaches to help both urban and rural women. Service providers increase engagement by adapting services to include outreach, home visitation and mentoring, and tailoring messages to be welcoming to women who are pregnant and to young women. The challenges of rural and northern living can affect engagement and outreach efforts by both service providers and women in need of support, and needs attention. 3 Specialized holistic support includes support on substance use issues, in combination with support on other health and social concerns such as mental health problems, experience of childhood abuse, trauma, violence in the home, poverty, homelessness, child custody, and other issues affecting pregnant women and mothers. This welcoming and integrated form of support can be especially important where structural violence and colonization have caused discrimination and oppression. 4 Structured substance use treatment is complicated by a lack of women s treatment spaces overall and in particular, for rural and northern women. Treatment options include day programs, outpatient counselling, residential treatment, mobile treatment, retreats and land-based programming but access is not universal, especially for rural and northern women. Fostering this continuum of care rests on continued and intensive efforts in communities to build awareness and actively prevent FASD. This can be achieved by engaging with women and girls about alcohol use, to help reduce alcohol consumption and eliminate stigma associated with women s alcohol use (whether pregnant or not). In turn, this can help build healthier communities that are overall supportive of health and wellness. Components of the continuum of care currently exist in many communities and when extending this continuum, it is important to build on and integrate the current community-based programming. Discussion & Brief Intervention Structured Treatment Outreach & Engagement Specialized Holistic Support Two key themes pertinent to the successful prevention and treatment of substance use and FASD emerged from both the literature and the focus groups: Attending to the real life context that women are situated within family, community, children, safety and recognizing how that context influences women s capacity to access, complete, and maintain treatment. Understanding that a continuum of care is vital to the success of prevention and treatment endeavours. A continuum of care can address the needs of women at different levels of risk and assist them to stay in their communities. Attending to these two themes was emphasized as critical to overcoming current barriers to care. 03
4 PROMISING PRACTICES IN ACTION The study participants identified specific programming for First Nations and Inuit women in various locations in Canada that demonstrate components of this continuum of treatment and support. 1 Discussion and brief intervention occur when prevention is promoted broadly in a community and addressed by those working with women and girls, such as nurses, doctors, pregnancy outreach services, youth counsellors, and sexual assault service providers. Awareness is a key step in prevention, and the conversation about the impacts of alcohol use and related issues needs to be put on the table by service providers in collaboration with women. For example, Pauktuutit Inuit Women of Canada works in developing and delivering community-based training for both professionals and women on a range of women s health issues, including FASD prevention, teen pregnancy, tobacco reduction, violence and sexual health. Such training encourages participation by women in their own health care as well as helping professionals better identify and assist women. 2 3 Outreach and engagement can be challenging for it requires tailoring messages and directing programming that recognizes and addresses the specific concerns of women of varying ages, those in rural settings, and those in urban settings. Canada Prenatal Nutrition Programs reach out to thousands of women in rural and urban communities across Canada with group programming on nutrition and substance use issues. On the other hand, some outreach and engagement can be individual, as in mentoring-the-mentor programs. For example, in the SOAR Mentoring Program offered by Inter Tribal Health Authority in BC, women are mentored with the goal of reducing harm to the woman who is pregnant and/or in the postpartum period and of improving outcomes for her children. The approach is individual yet other community resources are engaged. Specialized holistic support is primarily available only in urban areas. It has been found to be helpful in preventing FASD by supporting the changes women have been able to make, and by continuing to help women identify personal risks and strengths. Leaders in holistic community-support programs have found that a non-judgmental, harm reduction service approach helps reduce barriers to care. Sheway in Vancouver, BC provides such programming that is inclusive of mothers, their children, their partners and families. Sheway provides services including nutritional support; pre and post natal medical care; support and counselling on substance use; HIV, STD, and Hep C support; help in avoiding violence and building supportive relationships; parenting support, and so forth. 04
5 The Women and Children s Healing and Recovery Program in Yellowknife is able to offer individual therapy, group counselling, life skills and parenting programs, case management, advocacy and crisis intervention for both women and their children. The WCHRP acknowledges how trauma is a root cause of many self-destructive behaviours such as addictions. Empowerment is seen as a key strategy to support healing and recovery that involves women reclaiming their voices in the decisions that affect their lives, regaining traditional skills and knowledge, as well as gaining new information and skills that they need to lead healthy lives. 4 Structured treatment for First Nations and Inuit women, other than structured outpatient counselling, is very limited. Although there are 58 treatment centres funded through NNADAP, most offer outpatient counselling only. Intensive day, land-based and residential treatment programming for First Nations and Inuit women can be located far from those who need the service. For example, there are few First Nations and Inuit treatment centres in the north: Nats ejee K eh Treatment Centre located in Hay River, Northwest Territories offers co-ed and women only programming; Qauma Mobile in Nunavut has healers who form a team to travel to communities for one-month periods to provide healing and treatment to former residential school students, and to anyone who wants to heal from trauma or abuse; and Saputjivik, a twelve bed co-ed residential treatment centre in North West River, Labrador, offers an annual summer landbased treatment component for women. Study participants stressed the importance of access to treatment on the community level and beyond, which: includes cultural components; addresses coexisting trauma/ violence and mental health concerns with addictions; and links the support of mothers with their children. Foundational to this continuum of care are broad-based community development and inclusion programs, such as those offered by Northern Family Health Society in Prince George BC and the Elsipogtog First Nation in New Brunswick that involve making all services in the community accessible and tailored to people with FASD, and taking an active role in respectfully raising awareness of the importance of reducing or stopping alcohol use in pregnancy. 05
6 SYSTEM LEVEL SUPPORT FOR IMPROVING PREVENTION, OUTREACH AND TREATMENT Women s prevention and treatment service providers in Ontario developed a report directed at improving women and substance use addictions and treatment by helping services identify the components of best practices. Best Practices in Action: Guidelines and Criteria for Women s Substance Abuse Services in Ontario (2005) provides comprehensive guidelines to guide treatment providers in their work with women. Alberta s Women Working toward their Goals through AADAC Enhanced Services for Women (ESW) (2006) describes a crosssystems approach to treatment engagement and support with notable results such as reduced substance use, better nutrition, better mental and physical health, better parenting and stable housing. These women-specific frameworks, as well as the systems approach identified by the National Treatment Strategy Working Group (2008) can also be helpful to guide integrated service provision by programs supported by the First Nations and Inuit Health Branch. CONCLUSION In this study, we endeavoured to bridge what is currently known about substance use among First Nations and Inuit women with best practices in outreach and treatment for women with substance use problems and best practices in FASD prevention. We are aware of how much more development is needed to combine these interconnected components of prevention and treatment to create a clear and comprehensive strategy for substance use treatment and support for First Nations and Inuit women who are at risk of having a child with FASD. We hope that this report catalyzes further discussion of mechanisms for improving the overall health and well-being of First Nations and Inuit women with substance use problems, their children, their families, and their communities. A key recommendation is for governments to support forums that: involve pregnant women and mothers in reflecting on and making their needs known; and involve Aboriginal women, treatment service providers, researchers and policy makers in joint discovery and planning processes. There is a critical need for more action on this important issue, if we are to support the improvement of the health of First Nations and Inuit women, and to prevent disabilities such as FASD in the next generations. 06
7 SELECTED BIBLIOGRAPHY Aboriginal Healing Foundation. (2005). Reclaiming Connections: Understanding Residential School Trauma Among Aboriginal People. Ottawa, ON: Aboriginal Healing Foundation. Acoose, S., Dell, C., Desjarlais, V., C. Stirbys. (2007). Beginning with our voices: A study of the healing journeys of First Nations women from illicit drug use. Edmonton, AB: Issues of Substance Conference. Assembly of First Nations. (2007). Draft Framework Gender Balancing: Restoring Our Sacred Circle, from cmslib/general/afn s%20gender%20re- Balancing%20Framework_EN.pdf Chansonneuve, D. (2007). Addictive Behaviours Among Aboriginal People in Canada. Ottawa, ON: Aboriginal Healing Foundation. Gates Consulting. (June 30, 2006). Final Report: Review of Women s Substance Abuse Treatment System in Ontario, from ResidentialSubstanceAbusePrograms.pdf Greaves, L., Poole, N. and R. Cormier. (2002). Fetal Alcohol Syndrome and Women s Health: Setting a Women-Centred Research Agenda. Vancouver, BC: BC Centre of Excellence for Women s Health. Health Canada. (1999). The Health of Aboriginal Women. Ottawa, ON: Health Canada. Health Canada. (2001). Best Practices Treatment and Rehabilitation for Women with Substance Use Problems. Ottawa, ON: Canada s Drug Strategy Division. Health Canada. (2001). It Takes a Community, Framework for the First Nations and Inuit FAS/FAE Initiative. A Resource Manual for Community-based Prevention of Fetal Alcohol Syndrome and Fetal Alcohol Effects. Ottawa, ON: First Nations and Inuit Health Branch. National Native Addictions Partnership Foundation. (April 2005). Framework for a Renewed Aboriginal Addictions System: Implementing the Strategic Recommendations of the 1998 General Review of the National Native Alcohol and Drug Abuse Program. Muskoday, SK: NNAPF. National Treatment Strategy Working Group. (2008). A System s Approach to Substance Use in Canada: Recommendations for a National Treatment Strategy. Ottawa, ON: National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada. Parks, C. A. (2003). Factors affecting entry into substance abuse treatment: gender differences among alcohol-dependent Alaska Natives. Social Work Research, 27(3), Poole, N., & Trainor, J. (2000). Report on the Action Forum on Aboriginal Women s Health and Addictions Services. Victoria, BC: Ministry of Health. Poole, N., & Greaves, L. (Eds.). (2007). Highs and Lows: Canadian Perspectives on Women and Substance Use. Toronto, ON: Centre for Addiction and Mental Health. Poole, N. (2008). Fetal Alcohol Spectrum Disorder (FASD) Prevention: Canadian Perspectives. Ottawa, ON: Public Health Agency of Canada. Tait, C. L. (2000). A Study of the Service Needs of Pregnant Addicted Women in Manitoba. Winnipeg, MB: Prairie Women s Health Centre of Excellence. Tait, C. L. (2003). Fetal Alcohol Syndrome Among Aboriginal People in Canada: Review and Analysis of the Intergenerational Links to Residential Schools. Ottawa, ON: Aboriginal Healing Foundation. Watkins, M., & Chovanec, D. (March 2006). Women working toward their goals through AADAC Enhanced Services for Women. Edmonton, AB: Alberta Alcohol and Drug Abuse Commission. 07
8 Discussion of alcohol and other substance use by service providers with all women of child-bearing years is important to support women before alcohol problems become serious, and to help those who need treatment get connected. Who discusses alcohol and other substance use issues, and provides brief support and referral for women in your community, and is there room for improvement? Focus Group Questions What kinds of treatment are available to women in your community/region? (outpatient counselling, support groups, outreach programs, home visiting support, shelter programs, detox programs, harm reduction services, day or residential treatment, follow-up support, mobile treatment, internet support). What are the strengths of these services? Do you have suggestions for improvement to treatment services? One of the suggestions women have had for improving assistance to women with substance use problems is to provide support for substance use problems, depression/other mental health problems and violence/trauma issues together. Do you think integrating support on these 3 issues is important for women, and have you ideas for how this might work? Some women wish to bring their children to treatment with them and others wish to have child care provided so they can take the time in treatment just to focus on themselves. What are your thoughts about making treatment more accessible and helpful to mothers? What about going to treatment with a spouse or partner: Why or why not might that be helpful? Do you have other suggestions for improving substance use treatment for First Nations and Inuit women who are pregnant and/or in their childbearing years? Or suggestions to address the needs of young women and women with FASD themselves? Coalescing on Women and Substance Use Linking Research, Practice and Policy Printed on 100% Post-Consumer Recycled Paper